We Need Clear Thinking: There Should Be No Clash Between Public Option and Single Payer

There appears to be a deep divide within the progressive movement over how to fix health care -- a sometimes nasty food-fight between advocates of a public insurance option and those who favor a "single-payer" system. 


This split is diverting progressive energy from what is probably the most important domestic policy decision of our time. As Washington Post columnist Harold Meyerson noted, while there is extensive institutional support for a public insurance option, there's little "street heat." Progressives seem to be too busy arguing amongst themselves to apply effective pressure to sold-out lawmakers who are protecting insurance companies' profits. 

But the public insurance/single-payer rift is a false dichotomy, and it is distracting us from the real fight. Most systems that people think of as single-payer really aren’t. Something approaching single-payer exists in Canada, Australia and the U.K. But even in these countries, buying supplemental insurance from private insurers is commonplace. 

Has Any Country Gotten "Profits out of Health Care"? 

The reality is that virtually every advanced, wealthy country features a universal system -- we're the exception -- that is financed through a blend of public and private means. See, for example, this Wikipedia entry about the health care systems in Holland, Germany and Belgium -- all of which are commonly referred to as single-payer systems, but in fact have "multiple payers but with some single-payer features." Those features include: universal coverage regardless of citizens' ability to pay, heavy state regulation and either the ability to bargain for the best prices from providers or have prices set by the government. 

So, if you're a single-payer advocate (like I am) the question arises: Wouldn't you be happy to have something like Germany's system? When I lived in Berlin in the early 1990s, I had an accident, broke a bone and went to the ER without insurance. They X-rayed it, set it and gave me a bunch of happy pills to take home. Total bill: $10. 

Then there is the Cadillac of health care systems -- the French model. Would we be poorly served with something like the system that scores the highest among industrialized countries in most measures of patient satisfaction, access, longevity, child mortality, etc.? Of course not. 

The French enjoy guaranteed, quality health care from cradle to grave that is financed, in large part, through tax revenues. However, it is not a single-payer system.Thirty-five  percent of French hospital beds are in private facilities; over 9 in 10 French citizens have supplemental insurance and, as this backgrounder explains, "About 75 percent of the total health expenditures are covered by the public health insurance system. A part of the balance is paid directly by the patients and the other part by private health insurance companies that are hired individually or in group." 

When we talk about single-payer, what we're really saying is that guaranteeing access to decent health care -- just like sanitation and clean water or electricity -- should be considered a fundamental duty of the state. But from that point, there's no reason I can see to exclude the private sector entirely. We regulate utilities that provide those other vital services, and limit their profit margins, but we don't rely on the government alone to deliver our electricity. 

In France, "The state sees that the whole population has access to care; it dictates the types of care that are reimbursed, and to what degree, and what the role is of the different participating entities. The state is in charge of protecting patients' rights, elaborating policies and enforcing them. It is responsible for public safety." 

That sounds fine to me, even though I identify as a single-payer advocate. 

And the reason this is more than a semantic point is straightforward: The proposal before us today would, if done right -- and the devil is most certainly in the details -- achieve a hybrid public-private system with "some single-payer features," much like what citizens of other liberal democracies enjoy. 

Put another way, the idea of getting "private profit" out of health care, while perhaps appealing on ideological grounds, doesn't reflect what the rest of the world has done. A more practical goal is addressing our shortcomings, in part by shifting the balance between the public and private delivery of health care. Currently, the United States ranks dead last among the wealthiest nations in terms of the portion of our health dollars spent on public health. 

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The advantages of having a greater share of health spending in the public sector go beyond a very large insurance pool and the efficiencies of scale and bargaining power that come with it. Countries with a higher rate of public health spending end up with a different set of incentives.

Unlike a wholly fragmented system relying on only private and largely unregulated insurance -- where an insurer has no incentive to make sure you stay healthy, because when you get sick it's just as likely to be on someone else's dime -- public health providers tend to place greater emphasis on preventing illness rather than waiting until people get sick and seek costly treatment. 

A Debate About Tactics, Not a Fight Over Fundamentals 

Karen Dolan of the Institute for Policy Studies is right in arguing that the fissure between public-option fans and single-payer advocates is shallower than it appears at first blush: 

One problem in progressive circles that contributes to the confusion is the perception, real or not, that single-payer and public-option advocates are fighting each other, weakening support for both. Though some of that is going on, the greater problem is that people think that's what's going on, and thereby try to push each other out of the room.  

There are very few health care advocates who will tell you that a single-payer health care system is not the correct remedy for the U.S. health care crisis. What they instead will say is that single-payer is dead politically, and that Obama and the progressive Democrats' public option is the only politically viable option. 

This is a key point -- the divide that does exist in progressive circles is tactical, not ideological. Most of those pushing the public option would, if they had their druthers, enact a single-payer system. But they recognize that the two commercial enterprises that have spent the most on political lobbying in recent years are the "disease care" and insurance industries. 

Like single-payer advocates, they believe that a large insurance pool with extensive government regulation and some subsidies afford the greatest potential for (near) universality and cost containment.

And they think that given the choice -- given a demonstration that this approach works better than having a fragmented system of private insurers -- most people will eventually opt into the public plan, and we'll end up achieving something approaching a single-payer system -- although an American-style variation -- through the back door.

They just don't think single-payer is a viable proposal given the clout that Big Health wields in Congress, and I'm not idealistic enough to say that they're wrong. 

The reason this is an important distinction is simple: People can differ respectfully and in good faith when it comes to tactical differences, but arguments over fundamental philosophical differences tend to become heated, fast. 

Finally, the divisions over the role of public and private insurers distract from other things that we need to fix the system. We may differ on the role that private insurers might play in a revamped U.S. health care system, but there are other issues all progressives should be able to embrace.

We can agree on the need for payment reforms that would discourage providers from ordering endless and often ineffective procedures; we can agree on the need for tighter regulations that would keep insurers from cherry-picking the patients that they want to cover; and we can agree on the need for investing in a secure electronic records system that would cut down on the cost of shuffling paperwork -- estimated at 20-30 cents of each health care dollar we spend.

Understanding all of this leads, I think, to a lot more agreement among progressives than it appears at first blush. It refocuses the debate toward more productive questions: how much private sector involvement we want, and what structure we might adopt for health care financed through the private sector in order to keep the insurance industry's predations in check. 

It also explains why some single-payer advocates -- like me -- are advocating so fiercely for the legislation working its way through Congress to be done right, with a large public insurance pool that's not restricted from bargaining with providers, or otherwise forced to compete with private insurers on an uneven playing field.

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